breast - los angeles plastic surgeonthe university of california, los angeles. received for...

BREAST

Acellular Dermal Matrix for the Treatmentand Prevention of Implant-AssociatedBreast Deformities

Scott L. Spear, M.D.Mitchel Seruya, M.D.

Mark W. Clemens, M.D.Steven Teitelbaum, M.D.Maurice Y. Nahabedian,

M.D.

Washington, D.C.; and Los Angeles,Calif.

Background: Acellular dermal matrix has been increasingly accepted in pros-thetic breast reconstruction. Observed benefits include improved control andsupport of implant position, better implant coverage, and the suggestion of adecreased capsular contracture rate. Based on this positive experience, it is notsurprising that acellular dermal matrix would be applied to other challengingimplant-related problems. This study investigates the use of acellular dermalmatrix for correction or prevention of implant-associated breast deformities.Methods: Patients who underwent primary aesthetic breast surgery or second-ary aesthetic or reconstructive breast surgery using acellular dermal matrix andimplants between November of 2003 and October of 2009 were reviewed ret-rospectively. Patient demographics, indications for acellular dermal matrix, andacellular dermal matrix type and inset pattern were identified. Preoperative andpostoperative photographs, success or failure of the procedure, complications,and need for related or unrelated revision surgery were recorded.Results: Fifty-two patients had acellular dermal matrix placed alongside 77breast prostheses, with a mean follow-up of 8.6 months (range, 0.4 to 30.4months). Indications included prevention of implant bottoming-out (n � 6),treatment of malposition (n � 32), rippling (n � 20), capsular contracture (n �16), and skin flap deficiency (n � 16). Seventy-four breasts (96.1 percent) weremanaged successfully with acellular dermal matrix. Three failures consisted ofone breast with bottoming-out following treatment of capsular contracture, onebreast with major infection requiring device explantation, and one breast withrecurrent rippling. There was a 9.1 percent total complication rate, consistingof three mild infections, one major infection necessitating explantation, onehematoma, and one seroma.Conclusion: Based on this experience in 77 breasts, acellular dermal matrix hasshown promise in treating and preventing capsular contracture, rippling, implantmalposition, and soft-tissue thinning. (Plast. Reconstr. Surg. 127: 1047, 2011.)

Since 2006, an increasing number of studieshave highlighted the beneficial use of acellulardermal matrix in primary prosthetic breast

reconstruction.1–12 Reported benefits include bettercontrol of implant position, better implant support

and coverage, and the suggestion of a decreasedfrequency of capsular contracture.1–6,8–11,13–15 Gam-boa-Bobadilla placed human acellular dermal ma-trix alongside 13 breast prostheses with poor pecto-ralis major muscle coverage and found that 92percent of patients had a successful breast recon-

From the Department of Plastic Surgery, Georgetown Uni-versity Hospital, and the David Geffen School of Medicine atthe University of California, Los Angeles.Received for publication April 18, 2010; accepted August13, 2010.Presented in part at the 26th Annual Meeting of the North-eastern Society of Plastic Surgeons, in Charleston, SouthCarolina, September 23 through 27, 2009, and the 2010Plastic Surgery Senior Residents Conference, in Anaheim,California, January 20 through 23, 2010.Copyright ©2011 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e31820436af

Disclosure: Dr. Spear is a paid consultant forLifeCell and Allergan. Dr. Teitelbaum is a consul-tant for LifeCell, Allergan, and Kythera Biophar-maceuticals. Dr. Nahabedian is on the speaker’sbureau for LifeCell. Drs. Clemens and Seruya haveno financial interest in any of the products, devices,or drugs mentioned in this article.

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struction and 73 percent had an “excellent” aes-thetic outcome.2 In a series of 76 immediate, single-stage prosthetic breast reconstructions using humanacellular dermal matrix, Salzberg reported a 0 per-cent contracture rate and a 0 percent “serious” com-plication rate over a 52-month follow-up period.3Zienowicz and Karacaoglu observed a 0 percent rateof contracture, rippling, symmastia, or bottoming-out in a study of 30 immediate implant-breast re-constructions with human acellular dermal matrixover an 18-month mean follow-up period.6 Breuingand Colwell placed human acellular dermal matrixalongside 44 breast prostheses and identified a 0percent contracture rate, a 2.3 percent extrusionrate, and a 4.5 percent infection rate over a 6-monthto 3-year surveillance period.5

In addition to investigating the use of acel-lular dermal matrix in primary prosthetic breastreconstruction, a limited number of studieshave studied the application of acellular dermalmatrix in the treatment of breast implant–asso-ciated deformities.5,16 –19 Prosthetic breast surgerycan be complicated by either capsular attenuation,manifesting as implant malposition or rippling, orcapsular contracture, presenting as implant firm-ness or distortion. To correct breast implant rip-pling in 34 patients, Duncan used human acellulardermal matrix and observed an improvement inpalpable rippling, an average patient satisfactionof 85 percent, a 2.9 percent rate of capsular con-tracture, and a 2.9 percent rate of infection.16 Ina series of 10 patients with breast implant–relatedproblems, including rippling, bottoming-out, sym-mastia, and contracture, Baxter found that 80 per-cent of revisions were stable with the use of humanacellular dermal matrix.17 Breuing and Colwellreported a 0 percent recurrence of contracture in23 breasts treated with capsulectomy and humanacellular dermal matrix for implant-relatedcontracture.5 Most recently, Maxwell and Gabrieldemonstrated decreased rates of capsular contrac-ture and improved implant cushioning and stabi-lization using acellular dermal matrix in revision-ary aesthetic breast surgery of 78 patients.19

Given the safety and efficacy of acellulardermal matrix in primary prosthetic breastreconstruction1–6,9–11 and the encouraging prelim-inary data on the use of acellular dermal matrix inselect cases of secondary prosthetic breastsurgery,5,16–19 we hypothesize that acellular dermalmatrix may be a useful adjunct in the treatmentand prevention of some implant-associated defor-mities. The purpose of the present study is toreview experience with acellular dermal matrix forcorrection or prevention of implant-associated

breast deformities and describe the key technicalaspects. This is especially significant because manyof these problems have proven extraordinarily dif-ficult to consistently correct in the past.20–28

PATIENTS AND METHODSAn institutional review board–approved, ret-

rospective review was carried out on patients op-erated on between November of 2003 and Octo-ber of 2009 at Georgetown University Hospital(S.L.S. and M.Y.N.) and in the practice of StevenTeitelbaum, M.D. Patients who underwent pri-mary aesthetic breast surgery or secondary aes-thetic/reconstructive breast surgery using acellu-lar dermal matrix and implants were identified.Techniques to address breast implant–related de-formities often included a combination of implantexchange, device position change, capsule modi-fication, and placement of acellular dermal ma-trix. When warranted, devices were exchangedand/or relocated to a subglandular, prepec-toral, subpectoral, or neosubpectoral pocket.When necessary, capsule modification was per-formed by means of capsulotomy, capsulectomy,and/or capsulorrhaphy. Depending on thebreast implant–associated complication, acellu-lar dermal matrix was placed alongside breastimplants using a “reconstructive,” “gutter,”“symmastia,” or “overlay” technique.29

To treat difficult/recurrent capsular contrac-ture, rippling, or implant bottoming-out, or toprevent loss of inframammary fold definition andbottoming-out, the reconstructive technique isused (Fig. 1). This involves interpositional (be-tween the pectoralis major muscle and chest wall)placement of acellular dermal matrix, as de-scribed previously by the authors.8 In the case ofAlloDerm (LifeCell Corp., Branchburg, N.J.),acellular dermal matrix is oriented with the deepdermal surface facing the skin flaps and centeredover the mid arc of the inframammary/lateralmammary fold, providing maximal coverage andsupport where most necessary. Strattice (Life-Cell), in contrast, does not require such orienta-tion. Next, the inferior border of the acellulardermal matrix is sutured to the chest wall tissue,to best control the inframammary and lateralmammary folds. The appropriate device is thenplaced into the pocket and seated accordingly.Care is taken to achieve a “hand-in-glove” fit be-tween the breast device, acellular dermal matrixgraft, and breast skin flaps. The superior border ofthe acellular dermal matrix is then sutured to thepectoralis major muscle, minimizing gap forma-tion and thus the risk of direct exposure of the

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prosthesis to a mastectomy incision. To reduce therisk of fluid accumulation between the acellulardermal matrix and the breast implant or betweenthe acellular dermal matrix and the breast skinflaps, drains are placed. Similar to a skin graft, theacellular dermal matrix should appear relativelysmooth without major folds or wrinkles andshould be in good contact with the breast skinflaps to ensure proper take and integration.Drains are left in place until the output is less than30 ml over a 24-hour period.

To address inferior malposition, the guttertechnique is used to reinforce the fold repair(Fig. 2). Preoperatively, the site of the newly de-sired inframammary fold is noted and marked onthe patient. The operation begins with a skin in-cision and removal of the prior device. A capsu-lorrhaphy is then carried out in one or more rows,tacking the anterior and posterior leaflets of thecapsule together and to the chest wall, therebyrecreating the desired inframammary fold. An im-plant sizer is placed to verify that the inframam-mary fold is correctly set. To reinforce the foldrepair, an appropriate piece of acellular dermalmatrix is then selected and inset over the capsu-lorrhaphy suture line with 1 to 2 cm of overlap.The chosen implant is then placed in the reestab-lished pocket. A small drain is optional and com-pletes the operation.

For correction of recurrent medial malposition,the symmastia technique is used (Fig. 3). Preoper-atively, the site of the newly desired medial breastborder is marked on the patient. Initial operativesteps include the creation of a neosubpectoralpocket and/or performance of a multilayer breastcapsulorrhaphy to establish the desired medialbreast border, as described previously.20,30 To cre-ate a neosubpectoral pocket, the pectoralis majormuscle is dissected away from the anterior leafletof the capsule. The implant is kept in the capsuleas long as possible to facilitate dissection and isremoved through an open capsulotomy when it isno longer helpful. Of importance, the newly es-

Fig. 1. The “reconstructive” technique. Inset of an acellular der-mal matrix interpositional graft, lying between the pectoralis ma-jor muscle and chest wall. As an inferolateral sling, the acellulardermal matrix aids in supporting the implant and defining thebreast lower pole. (Reprinted with permission from LifeCellCorp.)

Fig. 2. The “gutter” technique, with placement of acellular der-mal matrix over the capsulorrhaphy suture line to reinforce thefold repair in the setting of lateral or inferior malposition. (Re-printed with permission from LifeCell Corp.)

Fig. 3. The “symmastia” technique, with creation of a neosub-pectoral pocket and inset of acellular dermal matrix along thepectoralis major muscle/capsule interface in the context ofmedial malposition. (Reprinted with permission from LifeCellCorp.)

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tablished pocket is purposely underdissected me-dially. Once the neosubpectoral pocket is formed,the original pocket is closed off by tacking theanterior and posterior leaflets of the capsule to-gether and to the chest wall. To prevent migrationof the device into the old implant space, an ap-propriate piece of acellular dermal matrix is thenplaced medially over the suture line and/or pec-toralis/capsule interface generally with 1 to 2 cmof overlap. If implant lower pole support is alsonecessary, the acellular dermal matrix inset can beextended with an inferior cuff to help cradle thedevice. A sizer or implant is used, sometimes inconjunction with temporary or permanent mari-onette (percutaneous, horizontal mattress) su-tures, to ensure that the acellular dermal matrix isin appropriate position and set on appropriatetension. The desired breast implant is then placed,followed by insertion of a single small drain asnecessary.

To address thin breast skin flaps, the overlay(between implant and capsule) technique is gen-erally used (Fig. 4). Preoperatively, areas of soft-tissue deficiency are marked out on the patient.Operative steps begin with an open capsulotomyand removal of the old device. Areas of capsularthinning are noted and verified with the preop-erative markings. Acellular dermal matrix is thenplaced inside the device pocket and draped overthe thin capsular regions. With the aid of a sizeror the final implant, the acellular dermal matrix isset on appropriate stretch and free of wrinkles orfolds on inset. Capsule and skin closure is carriedout in routine fashion.

Generally, patients were discharged on the dayof surgery or, in rare cases, on postoperative day1. Oral antibiotics were continued until drain re-moval, typically once the output was less than 30ml/day. Marionette (percutaneous, horizontalmattress) sutures, if used, were usually discontin-ued 7 to 10 days postoperatively under sterile tech-nique. This consisted of swabbing the externalskin sutures with alcohol, cutting one end of thesuture flush at the level of the skin, and pulling theother end of the suture out of the skin. Theseseries of maneuvers may help prevent introduc-tion of skin flora into the breast pocket and therisk of infection.

Office charts and hospital records were re-viewed retrospectively for patient demographics,indications for acellular dermal matrix, and typeof acellular dermal matrix and inset pattern. As-sociated demographics included patient age, bodymass index, former or active tobacco use, historyof chemotherapy, and exposure to radiotherapy.Indications for acellular dermal matrix use weresometimes multiple and included the preventionof implant bottoming-out and the correction ofcapsular contracture, rippling, implant malposi-tion, and soft-tissue thinning. Depending on costand availability, human-derived acellular dermalmatrix, specifically AlloDerm, or porcine-derivedacellular dermal matrix (Strattice) was used.

Preoperative and postoperative photographs,failure of the procedure, complications, and needfor related and unrelated revision surgery wererecorded. Complications assessed included infec-tion, implant loss or exposure, hematoma, andseroma. Infections were categorized as mild, de-fined as warmth, swelling, cellulitis, or nonpuru-lent drainage that was responsive to initial antibi-otic therapy; or severe, characterized as persistentor substantial warmth/erythema/swelling despiteantibiotic therapy. Related revision procedureswere defined as those operations performed toaddress an issue directly related to the perfor-mance of acellular dermal matrix placement. Un-related revision operations were defined as thoseprocedures performed to address an issue not as-sociated with the performance of acellular dermalmatrix placement.

For statistical analysis, the Fisher’s exact testwas used for evaluation of percentages or frequen-cies. A value of p � 0.05 was considered statisticallysignificant.

RESULTSOver a 6-year period, 52 patients (28 aesthetic

and 24 reconstructive) had acellular dermal ma-

Fig. 4. The “overlay” technique. Acellular dermal matrix is para-chuted into the device pocket with the use of marionette suturesand draped over thin capsular regions to address areas of soft-tissue deficiency.


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trix placed alongside 77 breast prostheses (43 aes-thetic and 34 reconstructive). Patient demograph-ics are summarized in Table 1. The mean age ofthe patients was 44.4 years, with a range of 21 to66 years, and the average body mass index was21.5. Among aesthetic patients, 82.1 percent werenonsmokers, 7.1 percent were former smokers,and 10.7 percent were active smokers. In recon-structive patients, 91.7 percent were nonsmokers,0 percent were former smokers, and 8.3 percentwere active smokers. Among reconstructive pa-tients, 41.7 percent had a history of radiotherapyand 45.8 percent had a history of chemotherapy.None of the aesthetic patients had a history ofradiotherapy or chemotherapy.

Indications for acellular dermal matrix aresummarized in Table 2 and included preventionof implant bottoming-out (n � 6) and treatmentof malposition (n � 32), rippling (n � 20), cap-

sular contracture (n � 16), and skin flap defi-ciency (n � 16). Of note, 26.9 percent of patientshad more than one indication for acellular dermalmatrix use. Among the 77 breast prostheses, 39had AlloDerm placement and 38 had Strattice.

Complication rates were 7.0, 11.8, and 9.1 per-cent for aesthetic, reconstructive, and total breastoperations, respectively (Table 3). Complicationsconsisted of three mild infections, one major infec-tion requiring explantation, one hematoma, andone seroma. Total complications were higher in ir-radiated versus nonirradiated breasts, although thiswas not found to be statistically significant (20.0 per-cent and 7.4 percent, respectively; p � 0.223). Com-parison of overall complication rates between Strat-tice and AlloDerm was not found to be statisticallysignificant (10.3 percent and 7.7 percent, respec-tively; p � 0.71).

Five breasts underwent unrelated revision sur-gery. After successful correction of bilateral im-plant bottoming-out with interpositional acellulardermal matrix grafts, one patient underwent bi-lateral revision augmentation-mastopexy becauseof a desire for smaller implants. After successfultreatment of left reconstructed breast (pedicledtransverse rectus abdominis musculocutaneousflap) symmastia with acellular dermal matrix, onepatient underwent transverse rectus abdominismusculocutaneous flap revision with raising of theinframammary fold. After successful correction ofleft implant inferior malposition with interposi-tional acellular dermal matrix graft, one patient un-derwent left implant size change and revisionmastopexy to improve symmetry opposite herreconstructed right breast. Finally, after success-ful correction of bilateral symmastia, one pa-tient underwent right implant size change andleft breast lipoinfiltration to address a supero-medial depression.

With a mean follow-up of 8.6 months (range,0.4 to 30.4 months), 74 breasts (96.1 percent) weresuccessfully managed with acellular dermal ma-

Table 1. Patient Demographics

Value (%)

No. of patientsAesthetic 28 (53.8)Reconstructive 24 (46.2)

Age, yrAverage 44.4Range 21–66

Mean BMI, kg/m2 21.5No. with preoperative chemotherapy

Aesthetic 0 (0.0)Reconstructive 11 (45.8)

No. with preoperative radiotherapyAesthetic 0 (0.0)Reconstructive 10 (41.7)

Smoking historyNo. of nonsmokers

Aesthetic 23 (82.1)Reconstructive 22 (91.7)

No. of former smokersAesthetic 2 (7.1)Reconstructive 0 (0.0)

No. of active smokersAesthetic 3 (10.7)Reconstructive 2 (8.3)

BMI, body mass index.

Table 2. Indications for Acellular Dermal Matrix inthe Treatment and Prevention of Implant-RelatedBreast Deformities

No.

Patients 52Operative breasts 77Indications* 90Malposition 32Rippling 20Capsular contracture 16Skin flap deficiency 16Prevention of bottoming-out 6*Indications are per breast and were sometimes multiple.

Table 3. Complications following Acellular DermalMatrix Use in the Treatment and Prevention ofImplant-Related Breast Deformities

Aesthetic Breasts(n � 43)

ReconstructiveBreasts (n � 34)

No. % of Breasts No. % of Breasts

Infection 1 2.3 3 5.9Explantation 1 2.3 0 0.0Seroma 0 0.0 1 2.9Hematoma 1 2.3 0 0.0Total 3 7.0 4 11.8


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trix. Three failures consisted of one breast withbottoming-out following treatment of capsular con-tracture, one breast with major infection followingsymmastia repair requiring device explantation anddelayed replacement, and one breast with recurrentrippling necessitating repeat acellular dermal matrixplacement (Table 4). Comparison of failure ratesbetween Strattice and AlloDerm was not found to bestatistically significant (5.3 percent and 2.6 percent,respectively; p � 0.62).

The first failure consisted of a 43-year-oldwoman with a history of multiple breast augmen-tations performed at an outside hospital to addressleft-sided infection and capsular contracture, whopresented with recurrent left capsular contrac-ture. The patient underwent left revision augmen-tation with insertion of a 450-cc, moderate-profile,silicone implant in a neosubpectoral pocket andplacement of acellular dermal matrix (10 � 16cm) as an interpositional graft between the pec-toralis major muscle and the chest wall (recon-structive technique). The acellular dermal matrixwas found intraoperatively to be too small to ad-equately serve as an inferolateral sling and still beattached at both the pectoralis major muscle andthe inframammary fold. Over the subsequentmonths, the patient presented with bottoming-outof her implant.

The second failure consisted of a 31-year-oldwoman with a history of multiple breast augmen-tations performed by an outside surgeon to cor-rect symmastia and who presented with recurrentsymmastia. The patient underwent bilateral revi-sion breast augmentation with insertion ofsmooth, round silicone implants in a neosubpec-toral pocket and placement of acellular dermalmatrix using the above-described symmastia tech-nique. Three weeks postoperatively, the patientpresented with increasing pain, redness, and swell-ing of the right breast. Fluid aspiration was con-sistent with a methicillin-resistant Staphylococcusaureus–associated abscess. The patient underwentdevice explantation and curettage of the implant

capsule, with preservation of the acellular dermalmatrix, given its good integration with the sur-rounding tissue. Six months later, the patient suc-cessfully underwent device replacement (smooth,round silicone) and experienced no further epi-sodes of infection.

The third failure consisted of a 32-year-oldwoman with a history of bilateral immediate breastreconstruction with tissue expanders and acellulardermal matrix who presented with bilateral upperpole rippling following implant exchange. Thepatient underwent bilateral revision breast recon-struction with placement of acellular dermal ma-trix as overlay grafts (between capsule and skinflaps) and reinsertion of original devices (smooth,round silicone). One month postoperatively, thepatient presented with erythema and wounddrainage along the left reconstructed breast. Thisinfection was managed by incision and drainage,debridement of 10 percent of the acellular dermalmatrix that was nonadherent, and placement of anew device. Four months later, the patient pre-sented with recurrent superolateral pole ripplingof the left reconstructed breast. This was success-fully managed with revision breast reconstruction,placement of acellular dermal matrix graft undertension from the lateral mammary fold to the cap-sule along the superolateral margin of the breast,and reinsertion of the original device.

CASE REPORTSCorrection of Capsular Contracture

A 44-year-old woman with a history of bilateral breast aug-mentation and left mastopexy performed at an outside hospitalpresented with recurrent right capsular contracture after fourprevious failed revisions (Fig. 5). To address this deformity, thepatient underwent bilateral revision augmentation with rightpartial capsulectomy, partial subpectoral (“dual-plane”) place-ment of smooth, round silicone implants [right, Allergan 15-265; left, Allergan 10-210 (Allergan, Inc., Irvine, Calif.)], andinsetting of Strattice (8 � 16 cm, each) interpositional graftsusing the reconstructive technique. Comparison of preopera-tive and 10-month postoperative photographs showed absenceof breast distortion and preservation of a natural breast con-tour.

Correction of Medial MalpositionA 39-year-old woman with a history of multiple bilateral

breast augmentation-mastopexy procedures presented withsymmastia (Fig. 6). To treat the deformity, neosubpectoralpockets were developed; implants were exchanged for smaller,smooth, round silicone implants (Allergan 20-350); and Strat-tice (8 � 8 cm, each) was placed using the symmastia techniqueover the pectoralis/capsule interface. Postoperative photo-graphs demonstrated successful treatment of symmastia, whichwas maintained at 8-month follow-up.

Correction of RipplingA 21-year-old woman with a history of multiple breast

augmentation procedures performed at an outside hospital

Table 4. Failure Rates following Acellular DermalMatrix Use in the Treatment and Prevention ofImplant-Related Breast Deformities

IndicationNo. of Failed

Breast Procedures (%)

Malposition 1/32 (3.1)Rippling 1/20 (5.0)Capsular contracture 1/16 (6.3)Skin flap deficiency 0/16 (0.0)Prevention of bottoming-out 0/6 (0.0)Total 3/77 (3.9)


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to address implant bottoming-out presented with bilateralbreast implant rippling (Fig. 7). Operative steps to correctthese deformities included medial capsulorrhaphies; re-placement of the original smooth, round silicone implants(Allergan 10-300) in a new partial subpectoral pocket; andinsetting of AlloDerm (4 � 16 cm each) both as an inter-

positional graft between the inferolateral edge of the pec-toralis major muscle and the inframammary fold, and as anoverlay graft between the capsule and the implant. Eighteen-month postoperative photographs showed no evidence ofrippling or implant bottoming-out, with stable correction ofimplant deformities.

Fig. 5. (Left) Preoperative view of a 44-year-old patient displaying right capsular contracture followingbilateral breast augmentation and left mastopexy at an outside hospital. The operative plan includedbilateral revision augmentation with right partial capsulectomy; partial subpectoral (“dual-plane”)placement of smooth, round silicone implants (right, Allergan 15-265; left, Allergan 10-210); and in-setting of Strattice (8 � 16 cm each) interpositional grafts using the reconstructive technique. (Right)The patient 10 months postoperatively, showing correction of capsular contracture and absence ofbreast distortion.

Fig. 6. (Left) Preoperative view of a 39-year-old female smoker with a history of multiple bilateral breast aug-mentation-mastopexy procedures presenting with symmastia. The operative plan included creation of neosub-pectoral pockets; implant exchange for smaller, smooth, round silicone implants (Allergan 20-350); and Strattice(8 � 8 cm each) placement using the symmastia technique over the pectoralis/capsule interface. (Right) Thepatient at 8 months postoperatively, showing successful treatment of symmastia and stable implant location.


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Fig. 7. Preoperative anteroposterior (above, left), oblique (above, right), and magnified (second from

below) views of a 21-year-old patient displaying bilateral breast implant rippling after multiple sub-

pectoral breast augmentation procedures performed at an outside hospital. Postoperative anteropos-

terior (second row, left), oblique (second row, right), and magnified (below) views obtained 18 months

after bilateral revision augmentation with placement of original smooth, round silicone implants (Allergan

10-300) under a partial subpectoral pocket and insetting of AlloDerm as interpositional grafts between the in-

ferolateral edge of the pectoralis major muscle and the inframammary fold and as overlay grafts between the

capsule and implant. Note the correction of implant rippling and appropriate implant position.


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Prevention of Bottoming-OutA 36-year-old woman with a history of active tobacco use and

100-lb weight loss following bariatric surgery presented for abilateral breast augmentation-mastopexy procedure (Fig. 8).The patient underwent bilateral circumvertical mastopexies;partial subpectoral placement of smooth, round saline implants(Allergan 68MP, 330 cc filled); and placement of AlloDerminterpositional grafts between the pectoralis major muscle andthe inframammary fold using the reconstructive technique.Comparison of preoperative and 9-month postoperative pho-tographs demonstrates stable and appropriate device position,without signs of soft-tissue stretch or implant bottoming-out.

DISCUSSIONThe treatment and prevention of implant-as-

sociated breast deformities, arising from capsularattenuation and contracture, remain significantchallenges to the plastic surgeon. Capsular atten-uation can manifest as implant malposition, bot-toming-out, or rippling, whereas capsular contrac-tion can be associated with implant firmnessand/or distortion. In addition, implant placementcan be complicated by surrounding soft-tissuethinning, putting the prosthesis at risk for threat-ened and/or actual exposure. Unfortunately, pasttechniques to address these various issues have notbeen highly predictable or durable.

Capsular contracture remains one of themost frequent complications and is the mostcommon reason for reoperation following aes-thetic and reconstructive prosthetic breastsurgery.31,32 Recently, the Inamed 6-year andMentor 3-year silicone breast implant core studies

reported capsular contracture rates of 8.1 to 14.8percent, 18.9 to 20.5 percent, 8.3 to 15.9 percent,and 16.3 percent for primary augmentation, revisionaugmentation, primary reconstruction, and revi-sion reconstruction, respectively.31,32 To addressthis problem, described techniques have includedopen capsulotomy,33–35 partial/total capsulec-tomy,35–37 implant exchange,38,39 and implant sitechange.14,23,40,41 Unfortunately, these techniquesdo not achieve 100 percent success and can pro-duce unintended or unpredictable results, some-times exchanging one implant deformity foranother.35,36,42,43 These techniques are even lesseffective in the setting of some more aggressivecases of capsule formation, such as early, rapid, orrecurrent capsular contracture.23

Given that the cause of capsular contracture islikely multifactorial,44 an interplay among subclin-ical infection, foreign body reaction, and localinflammation, we propose a multipronged treat-ment strategy. In an effort to maximize the like-lihood of successfully correcting early or recurrentcapsular contracture, we offer the option of exe-cuting all measures at the outset that may limit thelikelihood of recurrence rather than waiting forrecurrence to escalate the treatment plan. There-fore, we prefer to perform a capsulectomy, sitechange, implant exchange, and acellular dermalmatrix interpositional placement between thepectoralis major muscle and chest wall all at thesame setting. This is particularly true in patients

Fig. 8. (Left) Preoperative view of a 36-year-old patient with a history of active tobacco use and 100-lb weight lossfollowing bariatric surgery who presented for bilateral breast augmentation-mastopexy. The operative plan includedbilateral circumvertical mastopexies; partial subpectoral placement of smooth, round saline implants (Allergan 68MP,330 cc filled); and placement of AlloDerm interpositional grafts between the pectoralis major muscle and the infra-mammary fold using the reconstructive technique. (Right) Patient’s appearance 9 months postoperatively, with ap-propriate implant position and no sign of bottoming-out.


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with recurrent contractures who have failed pre-vious efforts. The capsulectomy, site change, andimplant exchange all serve to limit the bacterialload in the operative region and maximally alterthe tissue/implant milieu. Finally, interpositionalplacement of acellular dermal matrix between thepectoralis major muscle and chest wall serves tointerrupt inflammation and capsule formation be-yond the pectoralis major muscle’s coverage of theimplant, as confirmed by recent clinical and ex-perimental studies.13,15,45

In our experience, the combination of thesesteps, including adding acellular dermal matrix,offers more predictable, consistent, and persistentresults for the problem of capsular contracturethat has been notoriously hard to predictably cor-rect by other means. In our study, of 16 breastswith early/recurrent capsular contracture, therewas only one failure (6.3 percent). Furthermore,we observed a low rate of unintended problems,with only one breast developing postoperative bot-toming-out in the context of insufficient infero-lateral support. In that one case, there was a de-viation from the ideal technique because of aninsufficient size of acellular dermal matrix.

Implant malposition has historically been dif-ficult to correct with a high degree of certainty orlongevity. Traditional methods have included theuse of an adjustable implant25; capsulorrhaphywith or without mirror-image capsulotomy20,26,27;reinforcement with a capsular flap; site change toa subglandular, subpectoral, or neosubpectoralpocket30,40; and transcutaneous suturing.28 Theseprocedures are technically difficult and in many sur-geons’ hands unreliable and prone to recurrence.

In our experience, we reserve capsulorrhaphyfor simple fold adjustments at the inframammaryfold. For more challenging and complex malpo-sition, we perform site change sometimes with theuse of a neosubpectoral pocket. In instances ofrecurrent malposition with poorer quality tissues,we recommend combining acellular dermal ma-trix with capsulorrhaphy repair and/or a neosub-pectoral pocket. In our opinion, this providesadded assurance in reducing the likelihood ofrelapse by supporting the fold repair, offloadingtension on the capsulorrhaphy suture line, andshielding the implant from entering the old space.Indeed, our study attests to the efficacy of acellulardermal matrix for this purpose, with failure in onlyone of 32 breasts (3.1 percent).

Rippling is another implant-related problemthat has challenged plastic surgeons. Visible rip-pling typically affects the superomedial quad-rant of the breast and is most evident in the

upright, leaning-forward position. In contrast,palpable rippling usually presents in the infero-lateral or inferior aspect of the breast. To addressthese problems, known techniques have includedchanging to a smooth, silicone implant; sitechange to a subpectoral pocket; capsulorrhaphy todecrease the pocket size; and the use of autoge-nous tissues such as fat, fascia, scar tissue, capsule,or major muscle.21,22,24,46 In our experience, devicechange from a saline or textured implant to asmooth silicone implant may help correct bothvisible and palpable rippling. In contrast, sitechange to a subpectoral pocket can help visiblebut not inferolateral palpable rippling. Overall,these methods are not universally successful orpredictable, especially in situations with thin orpoor-quality local tissue. Furthermore, we havenot found our experience with lipoinfiltration forcamouflaging rippling to be compelling.

We have been encouraged by our experiencewith acellular dermal matrix placement for thetreatment of rippling instead of isolated deviceexchange, site change, capsulorrhaphy, or autog-enous tissue placement. As an interpositional graftbetween the pectoralis major muscle and chestwall, acellular dermal matrix provides inferolat-eral support of the implant and prevents its down-ward descent and subsequent visible rippling. Asan overlay graft, acellular dermal matrix can re-tailor the implant space to prevent descent andsubsequent visible rippling and can reinforce thincapsular flaps to minimize palpable rippling. In-deed, results of this study attest to the efficacy ofacellular dermal matrix, with failure occurring inonly one of 20 breasts (5.0 percent).

Breast skin envelope thinning also remainsdifficult to correct with a high degree of certaintyor longevity. Traditional methods have includedthe use of autogenous tissues such as fat, fascia,scar tissue, capsule, or major muscle.47–49 Overall,these methods are not universally successful orpredictable. In our experience, we recommendacellular dermal matrix as an overlay graft to re-inforce areas of capsular thinning. In our study,there were no failures among the 16 breasts withskin flap deficiency.

There may be a role for acellular dermal matrixin primary aesthetic breast implant surgery in themassive weight loss patient, where we recommendacellular dermal matrix to prevent loss of inframam-mary fold definition and bottoming-out. Given thatimplant bottoming-out can be a difficult problem tocorrect, we have offered a preemptive strategy inthose patients at highest risk for postoperativestretch deformities. As an interpositional graft be-


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tween the pectoralis major muscle and chest wall,acellular dermal matrix may provide inferolateralsupport and protect the overlying tissues from theweight of the implant. In this study, we had no oc-currences of implant bottoming-out in six post–bari-atric surgery breasts receiving preemptive acellulardermal matrix.

In addition to supporting the efficacy of acel-lular dermal matrix, this study also points to thesafety of acellular dermal matrix use in revisionaryprosthetic breast surgery. Among the 43 aestheticbreast cases, complication rates were low, with oneevent each of hematoma and infection with deviceexplantation. Equally low rates were observed for34 reconstructed breasts, with an 11.8 percentoverall complication rate that included three mildinfections and one seroma.

This study provides evidence for broader ap-plications for acellular dermal matrix, but it doeshave some shortcomings. The short averagelength of follow-up (8.6 months) may have un-derestimated the rate of relapse and revisions. Inaddition, the small study population (77 breasts)may have underpowered the analysis. This infor-mation, though early, is important for beginningto understand how the emerging technology ofacellular dermal matrix works. Indeed, the seniorauthor (S.L.S.) has placed acellular dermal matrixin an additional 37 patients with implant-relateddeformities since preparation of this article andhas noted continued satisfactory results.

CONCLUSIONSThe management and prevention of implant-

associated breast deformities remain difficult chal-lenges. Prior techniques have not been universallyreliable or predictable. Based on experience with 77breasts, acellular dermal matrix has shown promisein treating and preventing capsular contracture, rip-pling, implant malposition, and soft-tissue thinning.

Scott L. Spear, M.D.Georgetown University Hospital

3800 Reservoir Road, N.W.PHC Building, First Floor

Washington, D.C. [email protected]

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breast - los angeles plastic surgeonthe university of california, los angeles. received for...

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